Client Questionnaire For Non-Business Debtor
Section 1  Basic Information
Part A. Name and Address
Name:
Last
First
Middle
Telephone Number Home: _________________________ Work: _______________________________
Have you used any other names in the past eight years?  No
 Yes
If yes, list other names:
Social Security Number: ___ ___ ___ - ___ ___ - ___ ___ ___ ___
Driver' License No.:__________________ Expiration Date:___________
Address:
Date of Birth:____________
__________________________________________________________________________
City:
_______________________ State: __________ Zip: _______________________________
County:
_____________________
Have you lived at this address for at least 180 days?  No  Yes
Have you lived at this address for at least 730 days (2 years)?  No  Yes
If you answered no to either of the questions above, please list your previous address:
Address: ______________________________________________________________________
City: _____________________ __________ State: _______________________ Zip:
County: ________________
If you have a different mailing address, please list:
Mailing Address: _____________________________________________________________________
City:
_______________________ State: __________ Zip: _______________________________
Part B. Name and Address of Spouse
If you are filing jointly with your spouse, fill in the following information about your spouse:
Name:
Last
First
Has your spouse used any other names in the past eight years?  No
names:
Middle
 Yes If yes, list other
Social Security Number: ___ ___ ___ - ___ ___ - ___ ___ ___ ___
Driver' License No.:__________________ Expiration Date:___________
Address:
City:
Date of Birth:____________
(if different from your address): _______________________________________________
_______________________ State: _______ Zip: ______________
County: ___________
If your spouse has a different mailing address, please list:
Mailing Address: _____________________________________________________________________
City:
_______________________ State: __________ Zip: _______________________________
Part C. Prior/Pending Bankruptcy Cases
Has a bankruptcy case been filed by you or against you in the last 8 years?  No
 Yes
If yes, in which district of which state was the case filed? _____________________________________
Case Number: _____________________ Date filed: ________________________________________
Are there currently any bankruptcy cases pending against you, your business, your spouse, or your
spouse’s business?
 No  Yes
If yes, name of debtor: ____________________________ Relationship to you: __________________
Case Number: ________________ Date filed: ____________ Judge:
________________________
In which district of which state was the case filed?
Exhibit "C" to the Voluntary Petition
Do you own or have possession of any property that poses or is alleged to pose a threat of imminent and
identifiable harm to public health or safety?  No  Yes (If yes, please attach a list and description of the property.)
Debtors Who Reside as Tenants of Residential Property
If you rent your home, does a landlord hold a judgment against you?  No
 Yes
If yes, please provide the name and address of the landlord:
Name: ________________________________________________________________________
Address: ______________________________________________________________________
City: _____________________ __________ State: _______________________ Zip:
Section 2  Property
Part A. Real Estate (Schedule A)
List all real estate which you own or are a joint owner of, even if you still owe money on the property.
Address and description of property
Owned by
Husband,
Wife, Joint
or
Community
Client Questionnaire: Copyright©1996-2009 Best Case Solutions
Value
Your %
ownership, or $
amount, if you
and spouse are
not sole owners
Office Use
Only
List all mortgages,
home equity loans,
and liens:
What is the $ value of the
loan, lien or mortgage?
What is your monthly
payment? How many
payments are left?
Who issued the lien, loan
or mortgage? (Name,
Address of Institution)
Exemptions?
Page 3
Part B. Personal Property (Schedule B)
For each type of property listed below, indicate whether you own any property of that category, and, if you do, fill in the remaining information. You
can think of the value as the replacement value. For property acquired for personal or family use, replacement value is the price a retail merchant
would charge for a property of that kind, considering the age and condition of that property.
Type of Property
Yes/
No
Description & Location
Husband, Wife,
Joint,
Community
Office Use Only
Value
Exemptions?
1. Cash on hand
2. Checking/Savings
Account, Certificates of
deposit, other bank
accounts
3. Security deposits held
by utility companies,
landlord
4. Household goods,
furniture, including audio,
video, and computer
equipment
Client Questionnaire: Copyright©1996-2009 Best Case Solutions
Page 4
Type of Property
Yes/
No
Description & Location
Husband, Wife,
Joint,
Community
Office Use Only
Value
Exemptions?
5. Books, pictures, art
objects, records, compact
discs, collectibles
6. Clothing
7. Furs and jewelry
8. Sports, photographic,
hobby equipment, firearms
9. Interest in insurance
policies-specify refund or
cancellation value
10. Annuities
11. Interests in an
education IRA, as defined
in 26 USC § 530(b)(1)
12. Interests in pension or
profit sharing plans
Client Questionnaire: Copyright©1996-2009 Best Case Solutions
Page 5
Type of Property
Yes/
No
Description & Location
Husband, Wife,
Joint,
Community
Office Use Only
Value
Exemptions?
13. Stock and interests in
incorporated/
unincorporated business
14. Interests in
partnerships/joint ventures
15. Bonds
16. Accounts receivable
17. Alimony/family
support to which you are
entitled
18. Other liquidated debts
owed to you, including tax
refunds
19. Equitable or future
interests or life estates
20. Interests in estate of
decedent or life insurance
plan or trust
21. Other contigent/
unliquidated claims,
including tax refunds,
counterclaims
22. Patents, copyrights,
other intellectual property
23. Licenses, franchises
Client Questionnaire: Copyright©1996-2009 Best Case Solutions
Page 6
Type of Property
Yes/
No
Description & Location
Husband, Wife,
Joint,
Community
Office Use Only
Value
Exemptions?
24. Customer List or
other compilation
25. Automobiles, trucks,
trailers, and accessories.
26. Boats, motors, and
accessories
27. Aircraft and
accessories
28. Office equipment,
supplies
29. Machinery, fixtures
etc. for business
30. Inventory
31. Animals
32. Crops-growing or
harvested
33. Farming equipment
and implements
34. Farm supplies,
chemicals, feed
Client Questionnaire: Copyright©1996-2009 Best Case Solutions
Page 7
Type of Property
Yes/
No
Description & Location
Husband, Wife,
Joint,
Community
Office Use Only
Value
Exemptions?
35. Other personal
property of any kind not
listed.
Client Questionnaire: Copyright©1996-2009 Best Case Solutions
Page 8
Section 3  Debts
List below all debts that you owe, or that creditors claim that you owe.
Type of Debt
1. Creditor Name and Address
2. Account Number, if any
3. Date/range of dates when debt was
incurred
4. Contact person's name and address, if
different
Office Use Only
Amount
owed
Name and address of codebtor, if any
What is debt for?
Is debt secured by any property? (If so,
please list monthly payment and number of
months left.)
Do you
dispute
the
debt?
Sched
D, E or
F?
Lawsuit pending?
Collection agency
assigned? Counsel
for creditor?
Home loans/
mortgages
Car loans
Other bank
loans
Personal
loans
Student loans
Major credit
card debts
(Visa, Am Ex,
Mastercard,
Discover) continue on next
Client Questionnaire: Copyright©1996-2009 Best Case Solutions
Page 9
Type of Debt
page, if necessary
Type of Debt
1. Creditor Name and Address
2. Account Number, if any
3. Date/range of dates when debt was
incurred
4. Contact person's name and address, if
different
1. Creditor Name and Address
2. Account Number, if any
3. Date/range of dates when debt was
incurred
4. Contact person's name and address, if
different
Amount
owed
Name and address of codebtor, if any
What is debt for?
Is debt secured by any property? (If so,
please list monthly payment and number of
months left.)
Do you
dispute
the
debt?
Office Use Only
Office Use Only
Amount
owed
Name and address of codebtor, if any
What is debt for?
Is debt secured by any property? (If so,
please list monthly payment and number of
months left.)
Do you
dispute
the
debt?
Sched
D, E or
F?
Lawsuit pending?
Collection agency
assigned? Counsel
for creditor?
Unpaid credit
cards, (Visa,
Am Ex,
Mastercard,
Discover)
continued
Department
store credit
card debts
Other credit
card debts
(Gas cards,
phone cards,
etc.)
Cash
Advances
(from credit
cards)
Client Questionnaire: Copyright©1996-2009 Best Case Solutions
Page 10
Type of Debt
Unpaid
medical bills
Type of Debt
1. Creditor Name and Address
2. Account Number, if any
3. Date/range of dates when debt was
incurred
4. Contact person's name and address, if
different
1. Creditor Name and Address
2. Account Number, if any
3. Date/range of dates when debt was
incurred
4. Contact person's name and address, if
different
Amount
owed
Name and address of codebtor, if any
What is debt for?
Is debt secured by any property? (If so,
please list monthly payment and number of
months left.)
Do you
dispute
the
debt?
Office Use Only
Office Use Only
Amount
owed
Name and address of codebtor, if any
What is debt for?
Is debt secured by any property? (If so,
please list monthly payment and number of
months left.)
Do you
dispute
the
debt?
Sched
D, E or
F?
Lawsuit pending?
Collection agency
assigned? Counsel
for creditor?
Unpaid rent
Unpaid taxes
Unpaid
alimony or
child support
Unpaid
service fees
All other
unpaid
debts/bills
Client Questionnaire: Copyright©1996-2009 Best Case Solutions
Page 11
Section 4  Unexpired Leases and Contracts (Schedule G)
List below any leases or contracts that are still current that you are a party to. Include residential, car and business leases, and service or business
contracts.
Nature and Description of Contract
Name and Address of Other Party or Parties
Client Questionnaire: Copyright©1996-2009 Best Case Solutions
Date that Contract Expires
Page 12
Section 5  Current Income
Marital Status:
 Married
 Single
 Divorced
 Separated
 Widowed
List all dependents of you and your spouse, their ages, and their relationship to you:
Name
Part A. Debtor’s Income
Age
Relationship
Part B. Joint Debtor’s Income
1. What is your occupation? ________________
1. What is your spouse’s occupation?__________
2. Name and address of your employer:
2. Name and address of your spouse’s employer:
_______________________________________
_____________________________________
_______________________________________
_____________________________________
_______________________________________
_____________________________________
3. How long have you been employed there?_____
3. How long employed there? _________________
4. What is the gross amount of your paycheck, before
taxes/other deductions are taken out? $_______
4. What is the gross amount of your spouse’s paycheck,
before taxes/other deductions? $_____
5. How often do you get paid?  once a week
 every two weeks
 twice a month
 once a month

other_________________
5. How often does your spouse get paid?  once a
week  every two weeks  twice a month 
once a month  other_______
Complete the below questions with your estimate of
monthly averages.
6. Do you receive overtime pay outside of your salary?
If so, how much per month? $________
7. How much is taken out of each paycheck for taxes
and social security? $___________
8. How much is taken out for insurance? $_______
9. How much for union dues? $________
10. Are there other deductions? If so, what are they and
how much? __________________________
Do you receive
a) income from business operations outside of your
regular paycheck listed above? If so, what is the
business and how much do you receive per month?
b) income from real estate property? If so, how much
per month? No Yes $_________
c) interest or dividends? If so, how much per month?
No Yes $_________
d) alimony or family support payments for your use or for
the care of your dependents? If so, how much per
month? No Yes $_________
e) social security or other forms of monetary government
assistance? No Yes $______
f) retirement or pension money? No Yes$____
Complete the below questions with your estimate of
monthly averages.
6. Does your spouse receive overtime pay outside of
your salary? How much per month? $_______
7. How much is taken out of each paycheck for taxes
and social security? $___________
8. How much is taken out for insurance? $_______
9. How much for union dues? $________
10. Are there other deductions? If so, what are they and
how much? __________________________
Does your spouse receive
a) income from business operations outside of the regular
paycheck listed above? If so, what is the business and
how much does your spouse receive per month?
b) income from real estate property? If so, how much per
month? No Yes $________
c) interest or dividends? If so, how much per month?
No Yes $_________
d) alimony or family support payments for spouse’s use or
for care of dependents? If so, how much per month? No
Yes $_______
e) social security or other forms of monetary government
assistance? No Yes $_______
f) retirement or pension money? No Yes$____
Does your spouse have any other income not listed?
Do you have any other sources of income not listed?
Are you or your spouse expecting any increase or decrease in salary next year? If so, explain.
Client Questionnaire: Copyright©1996-2009 Best Case Solutions
Page 13
Section 5A  Current Monthly Income
Fill in your monthly income for the categories below in the column labeled "Month 1." If your income for one of the below categories varies from month to
month, complete the below chart by entering in your income for all six months.
Month 1
Month 2
Month 3
Month 4
Month 5
Month 6
Office Use
(last month)
(2 months ago)
___/___
___/___
___/___
___/___
Only
___/___
___/___
Gross wages, salary, tips,
bonuses, overtime, commissions.
Income from operation of
business:
a. Gross Income
- b. Expenses
= c. Net Income.
Rent and other real property
income:
a. Gross Income
- b. Expenses
= c. Net Income.
Interest, dividends, and royalties.
Pension and retirement income
(NOT Social Security).
Regular contributions from others
to the household expenses,
including child support.
Unemployment Compensation.
Social Security income.
Client Questionnaire: Copyright©1996-2009 Best Case Solutions
Page 14
Other sources not already
mentioned. Specify:
Client Questionnaire: Copyright©1996-2009 Best Case Solutions
Page 15
Section 6  Current Expenses
Do you and your spouse maintain separate households?  No  Yes. If so, fill one page out for your
household and another for your spouse’s.
The following questions ask for your expenses each month. If you are unsure of the amount you pay each
month, but know the amount for a different period (per week, per day, every 2 months, etc.,), write in the
amount and the frequency that you pay the amount.
Indicate how much you pay for each item each month…
1. your rent or your home mortgage
Does that amount include real estate taxes?  No  Yes
Does it include property insurance?  No  Yes
$_________________
2. electricity and heating
$_________________
3. water and sewage
$_________________
4. telephone service/long distance
$_________________
5. Do you have any other utility bills? If so, what, and how much per month?
__________________________________________________
$_________________
_________________________________________________
$_________________
__________________________________________________
$_________________
6. home maintenance, including repairs and general upkeep
$_________________
7. food
$_________________
8. clothing
$_________________
9. laundry and dry cleaning
$_________________
10. medical and dental expenses
$_________________
11. transportation (not including car payments)
$_________________
12. entertainment, recreation, newspapers, magazines
$_________________
13. charitable contributions
$_________________
14. insurance not deducted from paycheck
a) homeowner’s or renter’s insurance
b) life insurance
c) health insurance
d) auto insurance
e) other insurance_______________________
$_________________
$_________________
$_________________
$_________________
$_________________
15. taxes not deducted from paycheck
$_________________
16. installment payments for car, furniture, etc. (Specify)
__________________________________________________
$_________________
_________________________________________________
$_________________
__________________________________________________
$_________________
17. alimony, maintenance, support paid to others
$_________________
18. payments for support of dependents not living at home
$_________________
19. expenses from operation of business
$_________________
Additional Expenses (707(b) Expenses)
20. mandatory payroll deductions not already listed ______________
_________________________________________________
Client Questionnaire: Copyright©1996-2009 Best Case Solutions
$_________________
$_________________
Page 16
21. court ordered payments not already listed ___________________
$_________________
_________________________________________________
$_________________
__________________________________________________
$_________________
22. education necessary to maintain employment
$_________________
23. education for a physically or mentally challenged child
$_________________
24. childcare
$_________________
25. disability insurance (if not listed on line 14)
$_________________
26. health savings accounts
$_________________
27. care for elderly, chronically ill, or disabled family members
$_________________
28. protection from family violence
$_________________
29. education expense for your children under 18
$_________________
30. non-mandatory contributions to retirement accounts (including loan repayment)
_________________________________________________
$_________________
_________________________________________________
$_________________
31. other expenses not listed above __________________________
$_________________
_________________________________________________
$_________________
_________________________________________________
$_________________
_________________________________________________
$_________________
Client Questionnaire: Copyright©1996-2009 Best Case Solutions
Page 17
Section 7  Statement of Financial Affairs
If you are filing jointly with your spouse, include information about both you and your spouse. If you are
filing under chapter 12 or 13, and you are married and not separated, you must provide information about
your spouse even if you are not filing jointly.
If you have no information to report for a question, check the "NONE" box.
1. Income from employment or operation of business
State your gross income from employment or operation of a business: If you have not received an income
from employment during the two years immediately preceding this calendar year, check this box:
 NONE
Period
$ Amount
Source
Husband/Wife
January 1 of this year through
date of commencement of case
Last year, (January 1 - December 31)
The year before last,
(January 1 - December 31)
2. Income other than from employment or operation of business
State the amount of income received other than from employment or operation of business during the two
years immediately preceding the commencement of this case:
 NONE
Period
$ Amount
Source
Husband/Wife
During the last year
Year before last
3. Payments to creditors
If your debts are primarily consumer debts, list all payments on loans, installment purchases of goods or
services, and other debts, aggregating more than $600 to any creditor made within 90 days
immediately preceding the commencement of this case. Indicate with an asterisk (*) any payments
that were made on account of a domestic support obligation, or that were made as part of an
alternative repayment plan.
 NONE
Name and Address of Creditor
Dates of Payments
Client Questionnaire: Copyright©1996-2009 Best Case Solutions
Amount paid
Amount still owed
Page 18
b. If your debts are not primarily consumer debts, list each payment or other transfer, aggregating more
than $5,475 to any creditor made within 90 days immediately preceding the commencement of this
case.
 NONE
Name and Address of Creditor
Dates of Payments
Amount paid
Amount still owed[
c. All debtors. List all payments made within one year immediately preceding the commencement of this
case to or for the benefit of creditors who are or were "insiders". ("Insiders" include your relatives, your
business partners and their relatives, your corporations, or your affiliates.)
 NONE
Name and Address of Creditor
and Relationship to You
Dates of Payments
Amount Paid
Amount Still Owed
4. Suits, executions, garnishments and attachments
a. List all suits and administrative proceedings to which you are or were a party within one year preceding
the filing of this case.
 NONE
Caption of Suit
and Case Number
Nature of Proceeding
Court or Agency
and Location
Status or
Disposition
b. Describe all property that has been garnished, seized, or attached under any legal or equitable process
within one year immediately preceding the commencement of this case.
 NONE
Name and Address of Person/Company
for Whom the Property Was Seized (Creditor)
Client Questionnaire: Copyright©1996-2009 Best Case Solutions
Date of Seizure
Description
and Value of Property
Page 19
5. Repossessions, foreclosures, and returns
List all property that has been repossessed by a creditor, sold at a foreclosure sale, transferred through a
deed in lieu of foreclosure, or returned to the seller, within one year immediately preceding the
commencement of this case.
 NONE
Date of Repossession,
Foreclosure, Transfer or Return
Name and Address of Creditor
Description
and Value of Property
6. Assignments and receiverships
a. Describe any assignment of property for the benefit of creditors made within 120 days immediately
preceding the commencement of this case.
 NONE
Name and Address of Assignee
Date of Assignment
Terms of Assignment/Settlement
b. List all property which has been in the hands of a custodian, receiver, or court-appointed official within
one year immediately preceding the commencement of this case.
 NONE
Name and Address
of Custodian
Name and location of Court,
Case Title and Number
Date of
Order
Description and Value
of Property
7. Gifts
List all gifts or charitable contributions made within one year immediately preceding the commencement of
this case except ordinary and usual gifts to family members aggregating less than $200 in value per
individual family member and charitable contributions aggregating less than $100 per recipient.
 NONE
Name and Address
of Recipient
Relationship to You, if Any
Client Questionnaire: Copyright©1996-2009 Best Case Solutions
Date
of Gift
Description
and Value of Gift
Page 20
8. Losses
List all losses from fire, theft, gambling or other casualty within one year immediately preceding the
commencement of this case or since the commencement of this case.
 NONE
Description and Value
of Property
Description of Circumstances and
Amount Covered by Insurance, if Any
Date of Loss
9. Payments related to debt counseling or bankruptcy
List all payments made or property transferred by or on behalf of the debtor to any persons, including
attorneys, for consultation concerning debt consultation, relief under the bankruptcy law or preparation of
the petition in bankruptcy within one year immediately preceding the commencement of the case.
 NONE
Name and Address
of Payee
Date of
Payment
Name of Person
Who Paid, if Not You
Amount of Money/ Description
and Value of Property
10. Other transfers (including sale of your property)
a. List all other property, other than property transferred in your ordinary course of business or financial
affairs, transferred either absolutely or as a security within two years immediately preceding the
commencement of this case.
 NONE
Name and Address of Transferee
and Relationship to you
Date of Transfer
Description of Property
Transferred and Value Received
b. List all property you transferred within 10 years immediately preceding the commencement of this case to
a self-settled trust, or a similar device of which you are the beneficiary.
 NONE
Name of Trust or
Similar Device
Date of Transfer
Client Questionnaire: Copyright©1996-2009 Best Case Solutions
Amount of Money or Description
and Value of Property or Interest
Page 21
11. Closed financial accounts
List all financial accounts and instruments held in your name or for your benefit which were closed, sold, or
otherwise transferred within one year immediately preceding the commencement of this case.
 NONE
Name and Address
of Institution
Type and Number of
Account & Final Balance
Amount and Date
of Sale or Closing
12. Safe deposit boxes
List each safe deposit or other box or depository in which you have or have had securities, cash, or other
valuables within one year immediately preceding commencement of this case.
 NONE
Name and Address of
Bank or Other Depository
Name and Address of Those
With Access to Box or Depository
Description
of Contents
Date of
Transfer, if Any
13. Setoffs
List all setoffs made by any creditor, including a bank, against a debt or deposit of yours within 90 days
preceding the commencement of this case.
 NONE
Name and Address of Creditor
Date of Setoff
Amount of Setoff
14. Property held for another person
List all property that you hold or control that is owned by another person.
 NONE
Name and Address of Owner
Description and Value of Property
Location of Property
15. Prior address of debtor
If you have moved within the three years immediately preceding the commencement of this case, list all
residences during the last three years, excluding your present address.
 NONE
Address
Your Name at the Time
Client Questionnaire: Copyright©1996-2009 Best Case Solutions
Dates of Occupancy
Page 22
16. Spouses and Former Spouses
If you reside or resided in a community property state, commonwealth, or territory (including Alaska,
Arizona, California, Idaho, Louisiana, Nevada, New Mexico, Puerto Rico, Texas, Washington, or Wisconsin)
within the eight-year period immediately preceding the commencement of the case, identify the name of
your spouse and of any former spouse who resides or resided with you in the community property state.
 NONE
Name
17. Environmental Information.
For the purpose of this question, the following definitions apply:
"Environmental Law" means any federal, state, or local statute or regulation regulating pollution,
contamination, releases of hazardous or toxic substances, wastes or material into the air, land, soil, surface
water, groundwater, or other medium, including, but not limited to, statutes or regulations regulating the
cleanup of these substances, wastes, or material.
"Site" means any location, facility, or property as defined under any Environmental Law, whether or not
presently or formerly owned or operated by the debtor, including, but not limited to, disposal sites.
"Hazardous Material" means anything defined as a hazardous waste, hazardous substance, toxic
substance, hazardous material, pollutant, or contaminant or similar term under an Environmental Law
a. List the name and address of every site for which you received notice in writing by a governmental unit
that it may be liable or potentially liable under or in violation of an Environmental Law. Indicate the
governmental unit, the date of the notice, and, if known, the Environmental Law:
 NONE
Site Name and Address
Name and Address of
Governmental Unit
Date
of Notice
Environmental
Law
b. List the name and address of every site for which you provided notice to a governmental unit of a release
of Hazardous Material. Indicate the governmental unit to which the notice was sent and the date of the
notice.
 NONE
Site Name and Address
Name and Address of
Governmental Unit
Client Questionnaire: Copyright©1996-2009 Best Case Solutions
Date
of Notice
Environmental
Law
Page 23
c. List all judicial or administrative proceedings, including settlements or orders, under any Environmental
Law with respect to which you are or were a party. Indicate the name and address of the governmental unit
that is or was a party to the proceeding, and the docket number.
 NONE
Name and Address of
Governmental Unit
Docket Number
Status or Disposition
18 . Nature, location and name of business
a. If the debtor is an individual, list the names, addresses, taxpayer identification numbers, nature of the
businesses, and beginning and ending dates of all businesses in which the debtor was an officer, director,
partner, or managing executive of a corporation, partnership, sole proprietorship, or was a self-employed
professional within the six years immediately preceding the commencement of this case, or in which the
debtor owned 5 percent or more of the voting or equity securities within the six years immediately
preceding the commencement of this case.
If the debtor is a partnership, list the names, addresses, taxpayer identification numbers, nature of the
businesses, and beginning and ending dates of all businesses in which the debtor was a partner or owned 5
percent or more of the voting or equity securities, within the six years immediately preceding the
commencement of this case.
If the debtor is a corporation, list the names, addresses, taxpayer identification numbers, nature of the
businesses, and beginning and ending dates of all businesses in which the debtor was a partner or owned 5
percent or more of the voting or equity securities within the six years immediately preceding the
commencement of this case.
 NONE
Name
Taxpayer
I.D. Number(EIN)
Address
Nature of Business
Beginning and End
Dates of Operation
b. Identify any business listed in response to subdivision a., above, that is "single asset real estate" as
defined in 11 U.S.C. § 101.
 NONE
Name
Address
Client Questionnaire: Copyright©1996-2009 Best Case Solutions
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The following questions, #19-25, are only to be answered if you are a corporation or partnership or if
you have been, in the six years immediately preceding this case, an officer, director, managing
executive, or owner of more than 5% of the voting securities of the corporation; a partner, other than
a limited partner, of a partnership; a sole proprietor, or otherwise self-employed.
19. Books, records, and financial statements
a. List all bookkeepers and accountants who, within the two years immediately preceding the filing of this
bankruptcy case, kept or supervised the keeping of books of account and records.
 NONE
Name and Address
Dates Services Rendered
b. List all firms or individuals who, within the two years immediately preceding the filing of this bankruptcy
case, have audited the books of account and records, or prepared a financial statement of the debtor.
 NONE
Name
Address
Dates Services Rendered
c. List all firms or individuals who, at the time of the commencement of this case, were in possession of
your books of account and records. If the records are not available, explain.
 NONE
Name and Address
Comments
d. List all financial institutions, creditors and other parties, including mercantile and trade agencies, to
whom a financial statement was issued by the debtor within two years immediately preceding the
commencement of this case.
 NONE
Name and Address
Client Questionnaire: Copyright©1996-2009 Best Case Solutions
Date Issued
Page 25
20. Inventories
a. List the dates of the last two inventories taken of your property, the name of the person who supervised
the taking of each inventory, and the dollar amount and basis of each inventory.
 NONE
Date of Inventory
Inventory Supervisor
Dollar Amount of Inventory
(specify cost, market, or other basis)
b. List the name and address of the person possessing the records of each of the two inventories reported
in a.) above.
 NONE
Date of Inventory
Name and Address of Custodian of Inventory Records
21. Current partners, officers, directors, and shareholders
a. If your business is a partnership, list the nature and percentage of partnership interest of each member
of the partnership.
 NONE
Name and Address
Nature of Interest
Percentage of Interest
b. If your business is a corporation, list all officers and directors of the corporation, and each stockholder
who directly or indirectly owns, controls, or holds 5 % or more of the voting securities of the corporation.
 NONE
Name and Address
Title
Nature and Percentage
of Stock Ownership
22. Former partners, officers, directors and shareholders
a. If your business is a partnership, list each member who withdrew from the partnership within one year
immediately preceding the commencement of this case.
 NONE
Name and Address
Date of Withdrawal
b. If your business is a corporation, list all officers or directors whose relationship with the corporation
terminated within one year immediately preceding the commencement of this case.
 NONE
Name and Address
Title
Client Questionnaire: Copyright©1996-2009 Best Case Solutions
Date of Termination
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23. Withdrawals from a partnership or distributions by a corporation
If your business is a partnership or corporation, list all withdrawals or distributions credited or given to an
insider, including compensation in any form, bonuses, loans, stock redemptions, options exercised and any
other perquisite during one year immediately preceding the commencement of this case.
 NONE
Name and Address of
Recipient, and Relationship to You
Date and Purpose
of Withdrawal
Amount of Money or Description
and Value of Property
24. Tax Consolidation Group.
If the debtor is a corporation, list the name and federal taxpayer identification number of the parent
corporation of any consolidated group for tax purposes of which the debtor has been a member at any time
within the six-year period immediately preceding the commencement of the case.
 NONE
Name of Parent Corporation
Taxpayer Identification Number
25. Pension Funds.
If the debtor is not an individual, list the name and federal taxpayer identification number of any pension
fund to which the debtor, as an employer, has been responsible for contributing at any time within the sixyear period immediately preceding the commencement of the case.
 NONE
Name of Pension Fund
Taxpayer Identification Number
Client Questionnaire: Copyright©1996-2009 Best Case Solutions
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